Evaluation and Management Coding Practice: Sandy White is a 52-year-old white female established patient who was seen in the office by Dr. Kramer on January 15 with the chief complaint of low back pain. The patient has complained of lumbosacral pain off and on for many months, but it has been getting worse for the last two to three weeks. The pain is constant and gets worse with sneezing and coughing. There is no radiation of the pain to the legs.
Past History reveals no history of trauma, no history of urinary symptoms, and no history of weakness or numbness in the legs. She had measles during childhood. She's had high blood pressure for a few years. Sandy also has a previous history of rectal bleeding from hemorrhoids. She had an appendectomy and cholecystectomy in 1975. She also has diabetes mellitus, controlled by diet alone.
Family History: Sandy's mother died postoperatively at age 62 of an abdominal operation, the exact nature of which is not known. She had massive bleeding. Her father died at the age of 75 of a myocardial infarction. He also had carcinoma of the bladder and diabetes mellitus. One sister has high blood pressure.
Social History: She is widowed. She smokes and drinks, but just socially. Her job at the Evening Tribune involves heavy lifting.
Systemic Review reveals no history of cough, expectoration, or hemoptysis. No history of weight loss or loss of appetite. No history of thyroid or kidney disease. The patient has been overweight for many years. HEENT is unremarkable; hearing and vision are normal. Cardiorespiratory reveals no known murmurs. GI reveals no food allergies or chronic constipation. GU reveals no nocturia, enuresis, or GI infection. Neuromuscular reveals no history of paralysis or numbness in the past.
Physical Examination in the office reveals a slightly obese, middle-aged female in acute distress with lower back pain. Pulse is 80, blood pressure is 140/85, respirations 16, temperature 98.4°F. HEENT: PERRLA. Conjunctivae are not pale. Sclerae are not icteric. Fundi show arteriolar narrowing. Neck: No thyroid or lymph node palpable. No venous engorgement. No bruit heard in the neck. Chest: PMI is not palpable. S1, S2 normal. No gallop or murmur heard. Chest moves equally on both sides with respirations. Breath sounds are diminished. No adventitious sounds heard. Abdomen: She has scars from her previous surgery. There is no tenderness. Liver, spleen, and kidneys are not palpable. Bowel sounds normal. Extremities: Leg-raising sign is negative on both sides. Both femorals and dorsalis pedis are palpable and equal bilaterally. There is no ankle edema. Central Nervous System: Speech is normal. Cranial nerves are intact. Motor system is normal. Sensory system is normal. Reflexes are equal bilaterally.
Impression: The impression is lumbosacral pain. The patient is being referred for physical therapy treatment twice per week. Darvocet-N will be prescribed for the pain.
E/M category/subcategory: Office or Other Outpatient Services, Established Patient
Determine the extent of history obtained:
Determine the extent of examination performed:
Determine the complexity of medical decision making:
complexity
CPT E/M code:
To determine the extent of history obtained, you need to review the patient's history section of the given information. In this case, the history includes Past History, Family History, and Social History. Here are the elements mentioned in the history:
Past History: No history of trauma, urinary symptoms, weakness, or numbness in the legs. Measles during childhood. High blood pressure. Previous history of rectal bleeding from hemorrhoids. Appendectomy and cholecystectomy in 1975. Controlled diabetes mellitus.
Family History: Mother died postoperatively at age 62. Father died at age 75 of a myocardial infarction. Sister has high blood pressure.
Social History: Widowed. Smokes and drinks socially. Job involves heavy lifting.
Based on this information, the extent of history obtained is detailed.
To determine the extent of examination performed, you need to review the physical examination section of the given information. Here are the elements mentioned in the physical examination:
HEENT: PERRLA. Conjunctivae are not pale. Sclerae are not icteric. Fundi show arteriolar narrowing.
Neck: No thyroid or lymph node palpable. No venous engorgement. No bruit heard in the neck.
Chest: PMI is not palpable. S1, S2 normal. No gallop or murmur heard. Chest moves equally on both sides with respirations. Breath sounds are diminished. No adventitious sounds heard.
Abdomen: She has scars from her previous surgery. There is no tenderness. Liver, spleen, and kidneys are not palpable. Bowel sounds normal.
Extremities: Leg-raising sign is negative on both sides. Both femorals and dorsalis pedis are palpable and equal bilaterally. There is no ankle edema.
Central Nervous System: Speech is normal. Cranial nerves are intact. Motor system is normal. Sensory system is normal. Reflexes are equal bilaterally.
Based on this information, the extent of examination performed is detailed.
To determine the complexity of medical decision making, you need to review the plan or impression section of the given information. The plan or impression states that the patient is being referred for physical therapy treatment twice per week and Darvocet-N will be prescribed for the pain.
Based on this information, the complexity of medical decision making is moderate.
Therefore, the E/M category/subcategory is Office or Other Outpatient Services, Established Patient.
To determine the CPT E/M code, you need to match the extent of history obtained, the extent of examination performed, and the complexity of medical decision making to the appropriate level in the E/M guidelines. Each level corresponds to a specific range of CPT codes.